Named Insured
If you have questions while filling out this application, please call 800-362-3363. Are you an Agent or Broker? Please Click Here

VGM Member #: Web site:

DBA:

Street: P.O. Box:

City:







A value is required.



Entity is:






3. Are you a subsidiary of another entity or do you have any subsidiaries?

4. Have your ever carried insurance that was written on a "claims made" basis?
5. Limit of Liability requested:
Gross Revenue

Gross Receipts Breakdown by Percentage
(products sold or rented or services rendered) Gross Revenue must be broken into percentages and must equal 100%.
Equipment Sales/Rentals:     Services: * Installation of fixtures and equipment means the permanent installation of equipment and fixtures attached to, or part of, any building, structure or auto.
Apnea Monitor % Wheelchair Lifts % Sleep Study %
Ventilator % Stair Lifts % Pharmacy %
Defibrillator % Ceiling Lifts % Repair & Service %
Parenteral Therapy % Grab/Safety Bar % Other Svc. (please list) %
Diabetic Shoes % Braces % Permanent Installation:*
Liquid Oxygen % CPAP % Elevators %
Oxygen Cylinder % Nebulizers % Ramps %
Scooters/TriCarts % ADLs % Ceiling Lifts %
Beds, Walkers, Crutches % TENS Units % Stair Lifts %
CPMs % Latex Gloves % Wheelchair Lifts %
Enteral Therapy % LAL Mattress % Hand Controls in Autos %
Lift Chairs % Uniforms % Grab Bars %
Oxygen Concentrator % Disposables % Other Permanent Install %
Motorized Wheelchairs % Diabetes Monitoring %    
Wheelchairs % Diabetes Testing %    
Other product Rent/Sell %      


6. Do you customize, modify or repair any products?
If yes, which items?
7. Are you accredited by: JCAHO CHAP ACHC HQAA CEAC
8. Do you use any independent contractors for your business (1099)?
If yes, in what capacity?
9. Do you employ contract or subcontract labor for installation, service or repair of products?
10. Do you sell or rent products or provide services to hotels, resorts, casinos or other retailers (i.e. Wal-mart, Kmart, etc.)?
11. Do you draw plans, designs, or specifications for any products sold?
If yes, which products?
12. Do you manufacture any products?
13. Do you provide warranties or guarantees other than those provided by manufacturers?
14. Please check if you would like a quote for:
Hired and/or Non-Owned Auto $250,000 limit
*Supplemental Application Required
Employee Benefits Liability $1,000,000 limit
*Number of employees

Professional Liability
15. Please state the number of certified professionals by category:


16. Do you charge a fee for respiratory therapy services separate from the sale of rental equipment?
17. Do Pharmacists carry their own individual professional policy?
18. Is the pharmacy owner a registered pharmacist?
19. Are tests administered by a certified Polysomnographic Technologist (PST)?
20. Do you employ a medical director?
Prior Liability Insurance Experience


21. Have there been any claims filed or losses paid, or are you aware of any incidents which might give rise to a suit against you,
within the last (3) years?
If yes please explain below
Location Information
Same as Above
Main Location

Location #2

Location #3
Warranties

The warranties following will be made part of any policy issued under this program.

Warranted: The company named on the front hereof and as signed below does not engage in any of the following activities:

A. Manufacture of any product.
B. Re-Manufacture or re-building of any item (repairs allowed – see below).
C. Provide home health nursing, therapy or other medical or quasi-medical services of any kind.
D. Charge a fee for medically related services.
E. Sell or rent significant volumes of imported product (significant is deemed to be in excess of 5%).
F. Directly import any product.

Warranted: The company named on the front hereof and as named below will adhere to the following quality criteria to be eligible for (and remain eligible for) coverage under this insurance program:

A. Repair work allowed on owned or rented equipment only, by trained personnel and following manufacturers’ recommendations. No significant outside repair work is allowed.
B. The insured provides no express or implied warranties of merchantability, fitness for use, or safety other than those warranties insured is expressly authorized to provide as an agent on behalf of the manufacturer, by the manufacturer.
C. If oxygen is offered a true 24-hour service, program must exist.
D. Insured must have and designate a “Safety Manager” to receive, catalog and disseminate all safety and loss control information.
E. No injections or I.V. administration may be done by an insured unless the individual so doing is properly licensed and the administration is incidental to the sale or rental of the equipment and not on a fee basis.
F. Permanent installation of equipment must be disclosed and specifically approved by Insurer.
G. Customer agrees to no leasing or rental of equipment in off premises retail locations (malls, large retailer, hotels, resorts, casinos, etc.) without direct involvement of employed or subcontracted staff at the delivery point.

Warning!! This is an important document, which could affect your legal rights. Please read it again carefully and be certain it is correct and complete. Your signature below is your warranty to us that we can rely on this form. We have made no investigation of our own and the coverage decision will be based on this information. COVERAGE IS NOT BOUND OR STARTED BY THIS FORM. WE MAKE NO PROMISE TO INSURE. THIS IS ONLY A REQUEST FOR A QUOTE. YOU ARE NOT COVERED UNTIL AND UNLESS YOU RECEIVE A BINDER SO STATING.

The coverages that we are quoting from information on this form are Product/Completed Operations and Professional and/or General Liability Insurance. We base important decisions on your answers to these questions. We rely on the accuracy of your answers. If you have any questions about the form or your answers please ask your sales representative.
The questions in this application are not intended to, nor do they, indicate the existence, non-existence or limitations on any items of coverage. This document does not in any fashion determine the coverage provided.



If you want to be insured, you will have to check this box.